PA Forms and Request Types

We must always process for QL Increase requests before PA requests.

True

False

If a drug is Not Covered, we should attach the ETC form even if a drug-specific PA form populates in the dropdown.

True

False

If a medication has a Drug Edit of ST, which form should we attach?

Drug-specific PA Form

ETC Form

Restricted to Specialist Form

Universal Step Therapy Form

If a medication has a Drug Edit of PA, which form should we attach?

Drug-specific PA Form

ETC Form

Restricted to Specialist Form

Universal Step Therapy Form

If a medication has a Drug Edit of RS, which form should we attach?

Drug-specific PA Form

ETC Form

Restricted to Specialist Form

Universal Step Therapy Form

If a medication has a Drug Edit of NC, which form should we attach?

Drug-specific PA Form

ETC Form

Restricted to Specialist Form

Universal Step Therapy Form

Which of the following is a request type we will NEVER use?

Prior Authorization

Quantity Limit Increase

Reconsideration

Step Therapy

If a CGM (e.g., Dexcom, Freestyle) has Drug Edits: QL ST and Publishing Note: Prior authorization (exception) required if member is not currently utilizing insulin, which form should we attach?

Continuous Glucose Monitors PA Form

Step Therapy Form

ETC Form

Restricted to Specialist Form

If a CGM (e.g., Dexcom, Freestyle) has Drug Edits: PA QL, which form should we attach?

Continuous Glucose Monitors PA Form

Step Therapy Form

ETC Form

Restricted to Specialist Form

Medication has a Drug Edit of NC. Member doesn't have an MPA on file. Provider submits an ETC Form but checks Quantity Limit Increase box. What will our Request Type be?

Prior Authorization

Not Covered Drug

Quantity Limit Increase

Step Therapy

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